Demystifying Medicine

Topic Introductions for 2007

Shortly after the discovery of antibiotics, infectious disease and public health authorities proposed that infectious agents had been "tamed."
Not so .the combination of antibiotic-resistance, "new" bacteria and viruses, neglected or deteriorating public health measures, poverty,
malnutrition, immune-deficient patients, and bioterrorism have combined to render the previously stated optimism incorrect and create
continuing new and fearful challenges.

Human papillomavirus is the most prevalent STD in the world, occurring at some point in up to 75% of sexually active women. Nearly all
cervical cancers are directly linked to previous infection with one or more of the oncogenic types of HPV. Other risk factors for
cervical cancer include sexual activity at a young age, multiple sexual partners, immunosuppression and HIV infection.

Can a vaccine prevent infection and, therefore, cervical (and other) cancers? If so, who should get the vaccine? When? Males as well
as females? How long does vaccination last? Are there dangers to vaccination?

Human Papillomavirus and Cervical cancer

HPV is the most prevalent sexually transmitted infection in the world. And, unlike other STDs such as gonorrhea or HIV/AIDS, use of
condoms and other safe-sex practices may not be nearly as effective in preventing infection. This is because the papilloma virus
lives in the skin (squamous) cells covering the pubic area (vulva and shaft of the penis) as well as the interior cells lining the
vagina and cervix in women, and urethra and anus in both sexes. Condoms do not cover the entire shaft of the penis nor do they block
contact with pubic skin. Therefore, during intercourse, even with a condom, skin cells containing HPV can come in contact with a
woman's vulva or vagina, enabling the virus ultimately to reach the cervix. In addition, the friction of sexual intercourse is believed
to cause tiny, microscopic tears in the vaginal wall, making transmission far more likely. Moreover, even dead cells shed during
intercourse can contain the virus and remain infective for days (Roden, Lowy and Schiller 1997).

Primary Prevention

The most effective way to prevent cervical and other genital cancers would be a vaccine. Individuals would need to be immunized at an
early age before they are sexually active. The benefits of such a vaccine would be particularly significant in developing countries,
where women's healthcare services are minimal. Designing a vaccine, however, will not be easy because people's immune response appears
to be specific to the type of HPV. For example, a person protected against type 16 would still be at risk of infection with other
cancer-inducing types, such as 18 or 33. There also appear to be subtypes or variants within type 16, and perhaps with other types as
well. Finally, as mentioned above, the types of HPV associated with cervical disease vary by geographical area. With the increase in
international travel, the various carcinogenic types soon will be spread throughout the world. Therefore, a vaccine with a mixture of
several types would have to be created (Groopman 1999; Stewart et al 1996).

Despite these problems, safety testing of at least two vaccines that could protect women from cancer-linked papilloma viruses is underway.
Estimates are, however, that it will be several years before either would be available, and many more years before they would be affordable
in developing countries. Finally, there also are attempts to produce a therapeutic vaccine, one which would boost the immune system of
someone who is already infected and cause the cancer to regress or even disappear. These vaccines are targeted to inactivate the E6 and E7
proteins, those viral proteins that block the action of the cell growth regulating proteins (Rb and p53) (Massimi and Banks1997).

Until such time that a protective vaccine is widely available, primary prevention must focus on continuing to change sexual practices and
other behaviors that increase a person's risk of becoming infected. Just as with the fight against HIV/AIDS, risk reduction counseling
related to the risk factors listed above (Table 1) must be incorporated into all levels of the healthcare system, especially those dealing
with young people. The messages must include alerting teenagers that practices designed to minimize the risk of STD or HIV/AIDS exposure
(i.e., the use of male or female condoms) may not be as effective for HPV prevention.1 In addition, vigorous efforts to
discourage adolescents, especially young girls, from starting smoking and initiating sexual activity must be widely and continuously
disseminated.

Secondary Prevention

Although at present prevention of HPV infection is difficult, for women already infected the immediate need is:

to identify those with early, easily treatable precancerous lesions; and

to cost-effectively treat them before the lesions progress to cancer.

Since 1989, JHPIEGO has been exploring the feasibility of several low-cost alternatives for cervical cancer detection. Prominent among these is
unmagnified (naked eye) visual inspection using a dilute solution of acetic acid (VIA). In March 1999, researchers from JHPIEGO and the
University of Zimbabwe reported in The Lancet that the sensitivity (77%) and specificity (64%) of VIA are comparable to those
of good quality Pap smears. This large-scale study, which involved more than 10,000 women attending primary healthcare clinics in Zimbabwe,
confirmed the findings of similar studies in South Africa and India (Sankaranarayanan et al 1998). A second major finding from the Zimbabwe
study was that nurse-midwives, who did all the VIA tests, quickly learned to competently perform them. This finding is important because the
vast majority of developing country women who need to be tested live in areas where there are no doctors and where Pap smears may never be
available. Furthermore, unlike Pap smears that require several days to a week to get the results back, with VIA the results are available
immediately. As a consequence, these nurse-midwives were able to quickly and easily identify women with no disease, those with abnormal
findings suitable for immediate treatment and those with very large lesions or advanced disease requiring referral.

With the establishment of VIA as an acceptable alternative to Pap smears (Kitchener and Symonds 1999), it is now possible to offer VIA with
outpatient treatment of precancerous lesions at the same visit. For example, cryotherapy, which involves freezing the cervix with a liquid
coolant such as carbon dioxide to destroy the abnormal cervical tissue, is highly effective.

And cryotherapy has been used extensively throughout the world for more than 20 years (Cox 1999; Mitchell et al 1998; Olatunbosun, Okonofua
and Ayangade 1992). Cryotherapy is also one of the easiest methods to learn and can be performed by nurses and other healthcare workers. In
light of these promising epidemiologic studies and the availability of a simple, low-cost outpatient method of treatment, the opportunity to
markedly reduce the incidence of cervical cancer globally is at hand. As the first step (Phase 1) in this process, JHPIEGO is conducting
several safety, acceptability, feasibility and program effectiveness (SAFE) demonstration projects in separate regions of the world. These
SAFE projects are needed to:

show that nurses and midwives can competently perform both VIA and cryotherapy in low-resource settings,

demonstrate that nurses and midwives can confidently treat or refer women with abnormal (precancerous) lesions, and

document the acceptability and feasibility of cervical cancer testing that is directly linked to immediate treatment.

We anticipate the results of these studies will show that well-trained nurses and midwives can quickly and easily identify patients who are
appropriate for immediate treatment with cryotherapy or refer those requiring more aggressive treatment (or those with advanced disease). We
also expect to learn that a test, treat or referral program is a safe, acceptable and feasible approach for preventing cervical cancer in
low-resource settings. Finally, we anticipate identifying ways in which large-scale Cervical Cancer Prevention (CECAP) programs can be
implemented nationally through a combination of individual and community education, participation by local nongovernmental organizations and
women's groups, and sponsorship by indigenous service organizations and clubs.

This practical approach to preventing cervical cancer has the potential to reduce disease progression and death in a majority of women who
currently do not have access to Pap smears and physician-staffed services. Also, it has the potential to reduce referrals of women with early
lesions to higher levels of the healthcare system as well as increase the chance of detecting invasive cancer at an earlier stage when it can
be treated successfully. Finally, once a precancerous lesion is treated, a woman's risk of developing an infection with other HPV types may
be reduced for several years, while those women found to be normal may not need retesting for 5 or more years (Lonky et al 1997; Lonky et al
1999).

Summary

Human papillomavirus is the most prevalent STD in the world, occurring at some point in up to 75% of sexually active women. Nearly all cervical
cancers are directly linked to previous infection with one or more of the oncogenic types of HPV. Other risk factors for cervical cancer include
sexual activity at a young age, multiple sexual partners, immunosuppression and HIV infection. Lacking an appropriate vaccine for HPV, primary
prevention of cervical cancer must focus on condom use and changing sexual practices as well as other behaviors that increase a person's risk of
becoming infected with HPV.

For women already infected with HPV, the immediate need is to identify those with early, easily treatable precancerous lesions and to treat these
women cost-effectively before the lesions progress to cancer. Visual inspection using a dilute solution of acetic acid (VIA) has been established
as an acceptable alternative to Pap smears. Therefore, it is now possible to offer VIA with cryotherapy, an outpatient treatment that uses a
liquid coolant to destroy abnormal cervical tissue. Cryotherapy is highly effective and has been used extensively throughout the world for more
than 20 years. Once a precancerous lesion is treated, a woman's risk of developing an infection with other HPV types may be reduced for several
years, while those women found to be normal may not need retesting for 5 or more years.

Dementia (from Latin de- "apart, away" + mens (genitive mentis )
"mind") is the progressive decline in cognitive function due to damage or disease in the brain beyond what might be expected from
normal aging. Particularly affected areas may be memory, attention, language and problem solving, although particularly in the
later stages of the condition, affected persons may be disoriented in time (not knowing what day of the week, day of the month,
what month or even what year it is), place (not knowing where they are) and person (not knowing who they are). Symptoms of
dementia can be classified as either reversible or irreversible depending upon the etiology of the disease. Less than 10% of all
dementias are reversible. Dementia is a non-specific term that encompasses many disease processes, just as fever is attributable
to many etiologies.

Without careful assessment, delirium can easily be confused with dementia and a number of other psychiatric disorders because
many of the signs and symptoms are conditions present in dementia (as well as other mental illnesses including depression and
psychosis).

Epidemiology

The prevalence of dementia in the global community is rising as the global life expectancy is rising. Particularly in Western
countries, there is increasing concern about the economic impact that dementia will have in future, older populaces. In Australia,
the 2006 estimated prevalence of dementia is 1.03% of the population as a whole. It is a disease which is strongly associated with
age; 1% of those aged 60-65, 6% of those aged 75-79, and 45% of those aged 95 or older suffer from the disease.

Diagnosis

Proper differential diagnosis between the types of dementia (see below) will require, at the least, referral to a specialist, e.g.
a geriatric internist, geriatric psychiatrist, neurologist, neuropsychologist or geropsychologist. However, there are some brief
(5-15 minutes) tests that have good reliability and can be used in the office or other setting to evaluate cognitive status.
Examples of such tests include the abbreviated mental test score (AMTS) and the mini mental state examination (MMSE).

An AMTS score of less than six and an MMSE score under 24 suggests a need for further evaluation. Of course, this must be
interpreted in the context of the person's educational and other background, and particular circumstances. Routine blood tests are
usually performed to rule out treatable causes. These tests include vitamin B12, folic acid, thyroid-stimulating hormone (TSH),
C-reactive protein, full blood count, electrolytes, calcium, renal function and liver enzymes. Abnormalities may suggest vitamin
deficiency, infection or other problems that commonly cause confusion or disorientation in the elderly. Chronic use of substances
such as alcohol can also predispose the patient to cognitive changes suggestive of dementia.

A CT scan or magnetic resonance imaging (MRI scan) is commonly performed. This may suggest normal pressure hydrocephalus, a
potentially reversible cause of dementia, and can yield information relevant to other types of dementia, such as infarction
(stroke) that would point at a vascular type of dementia. Sometimes neuropsychological testing is helpful as well.

The final diagnosis of dementia is made on the basis of the clinical picture. For research purposes, the diagnosis depends on both
a clinical diagnosis and a pathological diagnosis (ie, based on the examination of brain tissue, usually from autopsy).

Types

The most common types of dementia are as follows and vary according to the history and the presentation of the disease: (Where
available the ICD-10 codes are provided. The first code refers to the dementia, and the second to the underlying condition.

(Q90) People with Down's syndrome have an increased risk of developing dementia of the Alzheimer's type. This risk
increases as the person ages.

Treatable causes

Less than 5% of a sample of dementia cases have a potentially treatable cause. These include:

(F02.8/E01-E03) Hypothyroidism

(F02.8/E51) Vitamin B1 (thiamine) deficiency

(F02.8/E53.8) Vitamin B12, Vitamin A deficiency

(F03/F32-F33) Depressive pseudodementia (note: dementia and depression can coexist in many patients and can be difficult
to differentiate.)

(G91.2) Normal pressure hydrocephalus

Tumor

Treatment

Except for the treatable types listed above, there is no cure to this illness, although scientists are progressing in making a
type of medication that will slow down the process. Cognitive and behavioral interventions may also be appropriate. Educating
and providing emotional support to the caregiver [or carer] is of importance as well.

How healthy are your coronary arteries? If you eat healthy foods, get physical activity
every day and don't smoke, you're well on your way to preventing symptoms of coronary artery disease  a leading type of heart disease.

The coronary arteries supply your heart with blood, oxygen and nutrients. When blood flow through the coronary arteries becomes
obstructed, it's known as coronary artery disease.

Since coronary artery disease often develops over decades, it can go virtually unnoticed until it produces a heart attack. But
there's plenty you can do to prevent coronary artery disease. Start by committing to a healthy lifestyle.

Signs and symptoms

If your coronary arteries become narrowed, they can't supply enough oxygenated blood to your heart  especially when it's beating
hard, such as during physical activity. At first, the restricted blood flow may not cause any symptoms. As the fatty deposits
continue to accumulate in your coronary arteries, however, you may have:

Chest pain. You may feel pressure or tightness in your chest, as if someone were standing on your chest. The pain
is usually triggered by physical or emotional stress. It typically goes away within minutes after stopping the stressful activity.
Atypical chest pain  more common in women  may be fleeting or sharp and noticed in the abdomen, back or arm.

Heart attack. If a coronary artery becomes completely blocked, you may have a heart attack. The classic symptoms of
a heart attack include crushing pain in your chest, pain in your shoulder or arm, and shortness of breath. Women are somewhat more
likely than men to experience other warning signs of a heart attack, including nausea and back or jaw pain. Sometimes a heart attack
occurs without any apparent signs or symptoms.

Causes

Coronary artery disease is thought to begin with damage or injury to the inner layer of a coronary artery, sometimes as
early as childhood. The damage may be caused by various factors, including:

Smoking

High blood pressure

High cholesterol

Certain diseases, such as diabetes

Radiation therapy to the chest, as used for certain types of cancer

Once the inner wall of an artery is damaged, fatty deposits (plaques) accumulate. If the surface of these fatty deposits
breaks or ruptures, blood cells called platelets will clump at the site to try to repair the artery. This clump can block the
artery, leading to a heart attack.

Risk factors

Men are generally at greater risk of coronary artery disease than are women. However, the risk for women increases after menopause.
A family history of heart disease and simply getting older increases the risk as well.

Other risk factors for coronary artery disease include:

Smoking

High blood pressure

High cholesterol

Diabetes

Obesity

Physical inactivity

Stress and anger

Risk factors often occur in clusters and may feed one another, such as obesity leading to diabetes and high blood pressure. When
grouped together, certain risk factors put you at an ever greater risk of coronary artery disease. For example, metabolic syndrome
 a cluster of conditions that includes elevated blood pressure, high triglycerides, elevated insulin levels and excess body fat
around the waist  greatly increases the risk of all types of heart disease.

C-reactive protein. Your liver produces C-reactive protein (CRP) in response to injury or infection. CRP is
also produced by muscle cells within the coronary arteries. CRP is a general sign of inflammation, which plays a central role
in atherosclerosis.

Homocysteine. Homocysteine is an amino acid your body uses to make protein and to build and maintain tissue.
But excessive levels of homocysteine may increase your risk of coronary artery disease and other cardiovascular conditions.

Fibrinogen. Fibrinogen is a protein in your blood that plays a central role in blood clotting. But too much
may promote excessive clumping of platelets, the type of blood cell largely responsible for clotting. That can cause a clot to
form in an artery, leading to a heart attack or stroke. Fibrinogen may also be an indicator of the inflammation that accompanies
atherosclerosis.

Lipoprotein (a). This substance forms when a low-density lipoprotein (LDL) cholesterol particle attaches to a
specific protein. The protein that carries lipoprotein (a) may disrupt your body's ability to dissolve blood clots. High levels
of lipoprotein (a) may be associated with an increased risk of cardiovascular disease, including coronary artery disease and heart
attack.

When to seek medical advice

If you have risk factors for coronary artery disease, talk to your doctor. He or she may want to test you for the condition 
especially if you have signs or symptoms of narrowed arteries. Even if you don't have evidence of coronary artery disease, your
doctor may recommend aggressive treatment of your risk factors. Early diagnosis and treatment may stop progression of coronary
artery disease and help prevent a heart attack.

Screening and diagnosis

The doctor will ask questions about your medical history, do a physical exam and order routine blood tests. He or she may suggest one or
more diagnostic tests as well, including:

Electrocardiogram (ECG). An electrocardiogram records electrical signals as they travel through your heart. An
ECG can often reveal evidence of a previous heart attack or one that's in progress. In other cases, Holter monitoring may be
recommended. With this type of ECG, you wear a portable monitor for 24 hours as you go about your normal activities. Certain
abnormalities may indicate inadequate blood flow to your heart.

Echocardiogram. An echocardiogram uses sound waves to produce images of your heart. During an echocardiogram,
your doctor can determine whether all parts of the heart wall are contributing normally to your heart's pumping activity. Parts
that move weakly may have been damaged during a heart attack or be receiving too little oxygen. This may indicate coronary artery
disease or various other conditions.

Stress test. If your signs and symptoms occur most often during exercise, your doctor may ask you to walk on a
treadmill or ride a stationary bike during an ECG. This is known as an exercise stress test. In other cases, medication to stimulate
your heart may be used instead of exercise.

Some stress tests are done using an echocardiogram. These are known as stress echos. For example, your doctor may do an ultrasound
before and after you exercise on a treadmill or bike. Or your doctor may use medication to stimulate your heart during an
echocardiogram.

Another stress test known as a nuclear stress test helps measure blood flow to your heart muscle at rest and during stress. It's
similar to a routine exercise stress test but with images in addition to an ECG. Trace amounts of radioactive material  such as
thallium or a compound known as sestamibi (Cardiolite)  are injected into your bloodstream. Special cameras can detect areas in
your heart that receive less blood flow.

Angiogram. To view blood flow through your heart, your doctor may inject a special dye into your arteries
before a chest X-ray. This is known as an angiogram. The dye outlines narrow spots and blockages on the X-ray images. If you
have a blockage that requires treatment, a balloon or stent can be used to improve the blood flow in your heart.

Electron beam computerized tomography (EBCT). This test, also called an ultrafast CT scan, can detect
calcium within fatty deposits that narrow coronary arteries. If a substantial amount of calcium is discovered, coronary
artery disease is likely. Other types of CT scans can also generate images of your heart arteries.

Magnetic resonance angiography (MRA). This technique uses magnetic waves to produce a 3-D image of your
coronary arteries, which your doctor can check for areas of narrowing or blockages  although the details may not be as
clear as those provided by an angiogram.

Complications

When your coronary arteries narrow, your heart may not receive enough blood when demand is greatest  particularly during physical
activity. This can cause chest pain or shortness of breath. If a cholesterol plaque ruptures, complete blockage of your heart artery
may trigger a heart attack.

The lack of blood flow to your heart during a heart attack leads to irreversible damage to your heart muscle. The amount of damage
depends in part on how quickly you receive treatment. If your heart has been damaged and can't pump enough blood to meet your body's
needs, you may experience heart failure.

Treatment

Lifestyle changes can promote healthier arteries. If you smoke, quitting is the most important thing you can do. Eat healthy
foods, and exercise regularly. Sometimes medication or procedures to improve blood flow are recommended as well.

Medications

Various drugs can be used to treat coronary artery disease, including:

Cholesterol medications. Aggressively lowering your low-density lipoprotein (LDL), or "bad," cholesterol
can slow, stop or even reverse the buildup of fatty deposits in your arteries. Boosting your high-density lipoprotein (HDL),
or "good," cholesterol may help, too. Your doctor can choose from a range of cholesterol medications, including drugs known as
statins and fibrates.

Aspirin. A daily aspirin or other blood thinner can reduce the tendency of your blood to clot, which may
help prevent obstruction of your coronary arteries. If you've had a heart attack, aspirin can help prevent future attacks.

Nitroglycerin. Nitroglycerin tablets, spray and patches can control chest pain by opening up your coronary
arteries and reducing your heart's demand for blood.

Angiotensin-converting enzyme (ACE) inhibitors. These drugs decrease blood pressure and may help prevent
progression of coronary artery disease. If you've had a heart attack, ACE inhibitors reduce the risk of future attacks.

Calcium channel blockers. These medications relax the muscles that surround your coronary arteries and
cause the vessels to open, increasing blood flow to your heart. They also control high blood pressure.

Procedures to restore and improve blood flow

Sometimes more aggressive treatment is needed. Here are a few options:

Angioplasty and stent placement (percutaneous coronary revascularization). In this procedure, your doctor
inserts a long, thin tube (catheter) into the narrowed part of your artery. A wire with a deflated balloon is passed through
the catheter to the narrowed area. The balloon is then inflated, compressing the deposits against your artery walls. A mesh
tube (stent) is often left in the artery to help keep the artery open. Some stents slowly release medication to help keep the
artery open.

Coronary artery bypass surgery. A surgeon creates a graft to bypass blocked coronary arteries using a
vessel from another part of your body. This allows blood to flow around the blocked or narrowed coronary artery. Because this
requires open heart surgery, it's most often reserved for cases of multiple narrowed coronary arteries.

Coronary brachytherapy. If the coronary arteries narrow again after stent placement, radiation may be used
to help open the artery again.

Laser revascularization. If standard treatments aren't effective, a new surgery known as laser
revascularization may be considered. During this procedure, a laser beam is used to make tiny new channels in the wall of
the heart muscle. New vessels may grow through these channels and into the heart to provide additional paths for blood flow.

On the research front

Researchers are exploring new techniques for treating coronary artery disease, such as gene therapy. In this experimental procedure,
genes and growth factor proteins may be injected through a catheter or directly into the heart to stimulate growth of new blood
vessels and restore blood flow to the heart. Gene-coated stents that could encourage the repair of coronary arteries are being
studied as well.

Prevention

Lifestyle changes can help you prevent or slow the progression of coronary artery disease.

Stop smoking. Smoking is a major risk factor for coronary artery disease. Nicotine constricts blood vessels
and forces your heart to work harder, and carbon monoxide reduces oxygen in your blood and damages the lining of your blood
vessels. If you smoke, quitting is the best way to reduce your risk of a heart attack.

Control your blood pressure. Ask your doctor for a blood pressure measurement at least every two years. He
or she may recommend more frequent measurements if your blood pressure is higher than normal or you have a history of heart
disease. Normal blood pressure is below 120 systolic/80 diastolic as measured in millimeters of mercury (mm Hg).

Check your cholesterol. Ask your doctor for a baseline cholesterol test when you're in your 20s and then at
least every five years. If your test results aren't within desirable ranges, your doctor may recommend more frequent
measurements. Most people should aim for an LDL level below 130 mg/dL. If you have other risk factors for heart disease, your
target LDL may be below 100 mg/dL. If you're at very high risk for heart disease  if you've already had a heart attack or
have diabetes, for example  you may need to aim for an LDL level below 70 mg/dL.

Keep diabetes under control. If you have diabetes, tight blood sugar control can help reduce the risk of
heart disease.

Get moving. Exercise helps you achieve and maintain a healthy weight and control diabetes, elevated
cholesterol and high blood pressure  all risk factors for coronary artery disease. With your doctor's OK, aim for 30 to 60
minutes of physical activity most days of the week.

Eat healthy foods. A heart-healthy diet based on fruits, vegetables and whole grains  and low in saturated
fat, cholesterol and sodium  can help you control your weight, blood pressure and cholesterol. One or two servings of fish a
week are also beneficial.

Maintain a healthy weight. Being overweight increases your risk of coronary artery disease. Weight loss is
especially important for people who have large waist measurements  more than 40 inches for men and more than 35 inches for
women  because people with this body shape are more likely to develop diabetes and heart disease.

Manage stress. Reduce stress as much as possible. Practice healthy techniques for managing stress, such as
muscle relaxation and deep breathing.

In addition to healthy lifestyle changes, remember the importance of regular medical checkups. Some of the main risk factors for
coronary artery disease  high cholesterol, high blood pressure and diabetes  have no symptoms in the early stages. Early detection
and treatment can set the stage for a lifetime of better heart health.

Also ask your doctor about a yearly flu vaccine. Coronary artery disease and other cardiovascular disorders increase the risk of
complications from the flu.

March 20, 2007, "Agents of Potential Bioterrorism: Small pox, anthrax"

There is much excellent literature regarding bioterrorism. The following are for general reading for those who are not expert in the field.

Alibek, K. and S. Handelman. Biohazard: The Chilling True Story of the Largest Covert Biological Weapons Program in the World - Told from Inside by the Man Who Ran it. 1999. Delta (2000) ISBN 0-385-33496-6

An unpredictable disease of the central nervous system, multiple sclerosis (MS) can range from relatively benign to somewhat
disabling to devastating, as communication between the brain and other parts of the body is disrupted. Many investigators
believe MS to be an autoimmune disease -- one in which the body, through its immune system, launches a defensive attack against
its own tissues. In the case of MS, it is the nerve-insulating myelin that comes under assault. Such assaults may be linked to
an unknown environmental trigger, perhaps a virus.

Most people experience their first symptoms of MS between the ages of 20 and 40; the initial symptom of MS is often blurred or
double vision, red-green color distortion, or even blindness in one eye. Most MS patients experience muscle weakness in their
extremities and difficulty with coordination and balance. These symptoms may be severe enough to impair walking or even standing.
In the worst cases, MS can produce partial or complete paralysis. Most people with MS also exhibit paresthesias, transitory
abnormal sensory feelings such as numbness, prickling, or "pins and needles" sensations. Some may also experience pain. Speech
impediments, tremors, and dizziness are other frequent complaints. Occasionally, people with MS have hearing loss. Approximately
half of all people with MS experience cognitive impairments such as difficulties with concentration, attention, memory, and poor
judgment, but such symptoms are usually mild and are frequently overlooked. Depression is another common feature of MS.

Is there any treatment?

There is as yet no cure for MS. Many patients do well with no therapy at all, especially since many medications have serious side
effects and some carry significant risks. However, three forms of beta interferon (Avonex, Betaseron, and Rebif) have now been
approved by the Food and Drug Administration for treatment of relapsing-remitting MS. Beta interferon has been shown to reduce the
number of exacerbations and may slow the progression of physical disability. When attacks do occur, they tend to be shorter and
less severe. The FDA also has approved a synthetic form of myelin basic protein, called copolymer I (Copaxone), for the treatment
of relapsing-remitting MS. Copolymer I has few side effects, and studies indicate that the agent can reduce the relapse rate by
almost one third. An immunosuppressant treatment, Novantrone (mitoxantrone), is approved by the FDA for the treatment of advanced
or chronic MS.

One monoclonal antibody, natalizumab (Tysabri), was shown in clinical trials to significantly reduce the frequency of attacks in
people with relapsing forms of MS and was approved for marketing by the U.S. Food and Drug Administration (FDA) in 2004. However,
in 2005 the drugs manufacturer voluntarily suspended marketing of the drug after several reports of significant adverse events.
In 2006, the FDA again approved sale of the drug for MS but under strict treatment guidelines involving infusion centers where
patients can be monitored by specially trained physicians.

While steroids do not affect the course of MS over time, they can reduce the duration and severity of attacks in some patients.
Spasticity, which can occur either as a sustained stiffness caused by increased muscle tone or as spasms that come and go, is
usually treated with muscle relaxants and tranquilizers such as baclofen, tizanidine, diazepam, clonazepam, and dantrolene.
Physical therapy and exercise can help preserve remaining function, and patients may find that various aids -- such as foot braces,
canes, and walkers -- can help them remain independent and mobile. Avoiding excessive activity and avoiding heat are probably the
most important measures patients can take to counter physiological fatigue. If psychological symptoms of fatigue such as
depression or apathy are evident, antidepressant medications may help. Other drugs that may reduce fatigue in some, but not all,
patients include amantadine (Symmetrel), pemoline (Cylert), and the still-experimental drug aminopyridine. Although improvement of
optic symptoms usually occurs even without treatment, a short course of treatment with intravenous methylprednisolone (Solu-Medrol)
followed by treatment with oral steroids is sometimes used.

What is the prognosis?

A physician may diagnose MS in some patients soon after the onset of the illness. In others, however, doctors may not be able to
readily identify the cause of the symptoms, leading to years of uncertainty and multiple diagnoses punctuated by baffling symptoms
that mysteriously wax and wane. The vast majority of patients are mildly affected, but in the worst cases, MS can render a person
unable to write, speak, or walk. MS is a disease with a natural tendency to remit spontaneously, for which there is no universally
effective treatment.

What research is being done?

The National Institute of Neurological Disorders and Stroke (NINDS) and other institutes of the National Institutes of Health (NIH)
conduct research in laboratories at the NIH and also support additional research through grants to major medical institutions across
the country. Scientists continue their extensive efforts to create new and better therapies for MS. One of the most promising MS
research areas involves naturally occurring antiviral proteins known as interferons. Beta interferon has been shown to reduce the
number of exacerbations and may slow the progression of physical disability. When attacks do occur, they tend to be shorter and less
severe. In addition, there are a number of treatments under investigation that may curtail attacks or improve function. Over a
dozen clinical trials testing potential therapies are underway, and additional new treatments are being devised and tested in animal
models.